Provider Demographics
NPI:1386640076
Name:BRANUM, GENE D (MD)
Entity Type:Individual
Prefix:
First Name:GENE
Middle Name:D
Last Name:BRANUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3778
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-3721
Mailing Address - Country:US
Mailing Address - Phone:208-726-3707
Mailing Address - Fax:208-726-4817
Practice Address - Street 1:180 1ST ST W
Practice Address - Street 2:#301
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-726-3707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230423208600000X
IDM-13897208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1386640076Medicaid
ID1386640076OtherBLUE CROSS OF ID
VA4013671OtherCIGNA
VA762089OtherSOUTHERN HEALTH
VA345912OtherANTHEM
VA1000870001OtherDME PROVIDER
VA1386640076Medicaid